Snapshot A 24-year-old woman presents to the emergency room with 6 hours of severe left lower quadrant abdominal pain and some moderate vaginal bleeding. She is sexually active with 1 male partner and uses condoms occasionally. She has a history of pelvic inflammatory disease. Her last period was 7 weeks ago. A transvaginal ultrasound is performed and shows a mass in the left adnexa. Introduction Overview ectopic pregnancy is any pregnancy outside the uterine cavity ruptured ectopic is when the structure containing the pregnancy (such as fallopian tube) ruptures second leading cause of maternal mortality Epidemiology Incidence 6-16% among women who present to the emergency department with vaginal bleeding and/or pain estimated overall incidence 0.28-2.1% of pregnancies in United States Location most commonly found in the fallopian tubes (96%) ampulla (75%) isthmus (12%) other sites abdomen hysterotomy scar (embedded in cesarean scar) cervix Risk factors prior ectopic pregnancy pelvic inflammatory disease (PID) intrauterine device (IUD) use although women with an IUD have a very low risk of becoming pregnant, if they do get pregnant then they have a higher risk of ectopic pregnancy than pregnant women without an IUD prior tubal surgery advanced maternal age ETIOLOGY Pathogenesis Implantation of fertilized egg outside of the uterine cavity Presentation History woman of reproductive age patient is sexually active missed recent period Symptoms usually present in first trimester 6-8 weeks after last normal menstrual period abdominal/pelvic pain may be sudden onset or slow onset no one typical type of pain may be constant/intermittent, sharp/dull, mild to severe referred shoulder pain may be present if rupture with sufficient blood to irritate diaphragm vaginal bleeding or spotting amenorrhea other symptoms of pregnancy breast tenderness frequent urination nausea temperature > 38°C (100.4°F) is unusual (look for infectious cause) may be asymptomatic Physical exam cervical motion tenderness adnexal mass blood in vaginal canal ruptured ectopic pregnancy may present with hypotension signs of shock acute abdomen Imaging Transvaginal ultrasound indications elevated β-hCG with no signs of uterine gestational sac on ultrasound is highly suspicious for ectopic assess for site of gestational sac with a yolk sac or embryo measuring the size will guide treatment findings peritoneal free fluid if ruptured if no mass visualized inside or outside uterus rely on serum β-hCG quantification (≥ 1500 mIU/mL or failure to double after 48 hours) to determine if ectopic "snowstorm" appearance of uterus indicates molar pregnancy Studies Labs urine pregnancy test: positive serum β-hCG ≥ 1500 mIU/mL indicates ectopic pregnancy if < 1500 mIU/mL, repeat test in 48 hours in ectopic pregnancy β-hCG does not increase at an appropriate rate β-hCG level will be less than double after 48-72 hours intrauterine pregnancy β-hCG will double after 48-72 hours Rh(D) typing and antibody screen Differential Ruptured ovarian cyst key distinguishing factors negative β-hCG (unless ruptures during pregnancy) vaginal bleeding not usually associated pelvic ultrasound may see thin wall of previous cyst may see free fluid (also in ruptured ectopic) Molar pregnancy key distinguishing factors β-hCG may be much higher than in typical pregnancy or ectopic pelvic ultrasound “snowstorm” appearance of uterus Spontaneous abortion key distinguishing factors β-hCG will decrease on 48-hour repeat test physical exam cervical os may be open on pelvic exam may have passage of fetal contents from vagina pelvic ultrasound may visualize intra-uterine pregnancy may be visualized on ultrasound Treatment Management approach follow up post-treatment β-hCG levels to ensure complete destruction of trophoblastic tissue Medical methotrexate indications β-hCG ≤ 5000 mIU/mL gestational sac < 3.5 cm no fetal heart tone contraindications patient currently breastfeeding RhoGAM (anti-D immune globulin) indications all Rh(D)-negative mothers given to prevent antibody formation Surgical laparoscopic salpingostomy indications patient does not meet criteria for medical management no signs of rupture laparoscopic salpingectomy indications evidence of rupture free fluid in pelvic cavity signs of shock including hemodynamic instability Complications Recurrent ectopic pregnancy incidence approximately 15% due to anatomic and functional changes in fallopian tubes secondary to clinical or subclinical salpignitis Infertility incidence 11-62% risk factors prior history infertility pregnancy rate following ectopic pregnancy in women with history of infertility is 1/4 that of women without known infertility prior to ectopic decreased risk if ectopic occured during IUD use Death incidence approximately 31.9 per 100,000 pregnancies risk factors ruptured ectopic pregnancy severe hemorrhage from intraperitoneal bleeding Prognosis Life-threatening if rupture Pregnancy is non-viable